Monothérapie Bithérapie Trithérapie Autres Molécule
Dose
Début à j .. /durée
Désescalade thérapeutique : oui □ àj … Non □
Evolution
: ÆFavorable □ Critère clinique/paraclinique Défervescence thermique Nettoyage expectorations Bonne saturation disparition foyer Rx ↓ GB ↓CRP Autre Oui / non ÆDéfavorable □ Décès par :Tableau I : Le Clinical Pulmonary Infection Score (CPIS) [76] Température ≥ 36,5 °C et ≤ 38,4 °C 0 point ≥ 38,5 °C et ≤ 38,9 °C 1 point ≤ 36 °C ou ≥ 39 °C 2 points Leucocytose ≥ 4 G/L et ≤ 11 G/L 0 point < 4 G/L ou > 11 G/L 1 point si formes immatures ≥ 0,5 G/L +1 point Aspirations trachéales
< 4 + de sécrétions 0 point
≥ 4 + de sécrétions 1 point
si sécrétions purulentes +1 point PaO2/FIO2
> 240 ou SDRA 0 point
≤ 240 sans SDRA 2 points
Radiographie thoracique
absence d'infiltrat 0 point
infiltrat diffus 1 point
infiltrat localisé 2 points
Culture semi-quantitative des sécrétions trachéales (0, 1, 2 ou 3 +)
bactérie pathogène ≤ 1+ 0 point bactérie pathogène > 1+ 1 point si même bactérie sur Gram +1 point
Tableau II : Antibiothérapie probabiliste initiale recommandée selon le délai de survenue de la PNAVM et l’existence de facteurs de risque de BMR (adapté de [7] en 2005).
PN à début précoce (< 5 jours), sans facteurs de risque De BMR*, quelle que soit la gravité
PN à début tardif (> 5 jours) ou avec facteurs de risque de BMR*, quelle que soit la gravité
Germes potentiellement En cause ATB à spectre étroit Germes potentiellement en cause ATB à large spectre Cocci Gram+ S. Pneumoniae SAMS BGN : H. influenzae BG sensible E. coli Klebsiella pneumoniae Enterobacter spp. Serratia marcescens C3G ou Ampicilline+inhibiteur des β lactamases ou Fluoro-quinolones1 ou Ertapénème Cocci Gram+ et BGN précédents+ BMR P. aeruginosa K.pneumoniae(BLSE)* Acinetobacter sp.(BLSE)* + SAMR Legionelle pneumophila** C3G anti- pseudomonas² ou
Carbapénème anti- pseudomonas3 ou ßlactamine+inhibiteur de ßlactamases4 + Fluoro-quinolones anti-pseudomonas5 ou Aminoglycosides6 + vancomycine ou linézolide BMR* : bactéries multi-résistantes ,
1 : préfrer lévofloxacine ou moxifloxacine à la ciprofloxacine, 2 : céftazidime, céfipime,
3 : imipénème, méropénème, 4 : pipéracilline tazobactam, 5 : ciprofloxacine, lévofloxacine,
6 : amikacine, gentamycine ou tobramycine,
* :si suspicion de souche BLSE (bétalactamases à spectre élargie),on choisi les carbapénèmes, * *: association doit comporter un macrolide ou une fluoro-quinolone
Résumé
Les pneumopathies nosocomiales acquises sous ventilation mécanique (PNAVM) sont des causes principales de mortalité des patients hospitalisés en réanimation.
Ce travail consiste en une analyse épidémiologique des PNAVM dans le but d’évaluer l’incidence, les facteurs de risque, l’écologie bactérienne locale, le profil des résistances des germes, la stratégie thérapeutique, le pronostic et d’en déduire des mesures préventives.
C’est une étude rétrospective d’une série de 109 cas, hospitalisés en service de réanimation polyvalente du CHU Mohamed VI de Marrakech durant la période 2003-2007 et qui ont présenté une PNAVM.
L’incidence a été de 4,24%. Le diagnostic des PNAVM se base sur des critères cliniques, biologiques, radiologiques et bactériologiques avec essentiellement le prélèvement bronchique distal protégé dans nôtre série.
Le facteur de risque majeur a été la durée de la ventilation artificielle avec une moyenne de 15 jours (±10.09).
Les BGN représentent 61.4% des germes isolés (pseudomonas aéruginosae 38,5% , acinétobacter baumanii 22.7% , entérobacter cloacae 11.3%). Les cocci Gram positif représentent 30.5%, dont le staphylocoque en chef de fil avec prédominance du staphylocoque sensible à la méthiciline (SAMS) : 24,7%, SARM / SAMS = 0.33 (SARM : staphylocoque aureus résistant à la méthiciline).
Le traitement antibiotique s’est basé surtout sur la bithérapie 57.8% versus 38.5% pour la trithérapie utilisant surtout l’imipenème et l’amikacine avec une antibiothérapie orientée pour 49% versus empirique pour 51% des patients.
La mortalité est estimée à 51.4% contre une évolution favorable pour48,6% des patients. Le pronostic des PNAVM est corrélé au terrain, aux soins prodigués, au type de germe, au type et à la durée de l’antibiothérapie.
Au terme de ce travail nous proposons des mesures préventives se basant surtout sur le respect des règles d’hygiène et la formation continue du personnel vis-à-vis de ces mesures.
Summary
Nosocomial pneumopathies acquired under mechanical ventilation (PNAVM) are main causes of mortality of the patients hospitalized in reanimation.
This study consists of an epidemiological analysis of the PNAVM with the aim of estimating the incidence, the risk factors, the local bacterial ecology, the profile of the resistances of germs, the strategy Therapeutics, the forecast and to deduce from precautionary measures.
It is a retrospective study of series of 109 cases, hospitalized in reanimation of Mohamed VI Teaching Hospital of Marrakech during the period 2003-2007 and presenting PNAVM with an incidence of 4,24% and.
The PAVM diagnosis is based on clinical, biological, radiological and bacteriological criteria and mainly in our series the protected bronchial distal sampling. The major risk factor was the duration of the artificial ventilation with average of 15 days ( ±10.09 ).
The BGN represents 61.4 % of germs isolated (pseudomonas aeruginosae 38,5 %, Acinetobacter baumanii 22.7 %, enterobacter cloacae 11.3 %). The cocci Gram positive represent 30.5 % ; Staphylococcus are in the lead with predominance of staphylococcus sensitive to the methicilin (SAMS): 24,7% SARM/ SAMS= 0.33.
The antibiotic treatment is mainly based on the bitherapy 57.8 % versus 38.5 % for the tritherapy using especially the imipeneme and the amikacine with an antibiotic treatment adapted for 49.1 % versus empirical for 42.5%. The mortality is estimated at 51.4 % in ours series against a favorable evolution for 48,6 % of the patients.
The prognosis of the PNAVM is correlated with the ground, the lavished care, the type and duration of antibiotic treatment.
Finally, we suggest precautionary measures based especially on the respect of hygienization and an in-service training of the staff towards these measures.
ﺺﺨﻠﻣ
ﻥﻋ ﺞﺘﺎﻨﻟﺍﻭ ﻰﻔﺸﺘﺴﻤﻟﺍ ﻲﻓ لﻭﻤﺤﻤﻟﺍ ﻱﻭﺌﺭﻟﺍ ﺏﺎﻬﺘﻟﻻﺍ ﺩﻌﻴ
ﺔﻴﺴﻴﺌﺭﻟﺍ ﺏﺎﺒﺴﻷﺍ ﻥﻤ ﺔﻴﻋﺎﻨﻁﺼﻹﺍ ﺔﻴﻭﻬﺘﻟﺍ
ﺓﺯﻜﺭﻤﻟﺍ ﺔﻴﺎﻨﻌﻟﺍ ﺡﺎﻨﺠﺒ ﻥﻴﻤﻴﻘﻤﻟﺍ ﻰﻀﺭﻤﻟﺍ ﺕﺎﻴﻓﻭﻟ
.
،ﺭﻁﺨﻟﺍ ﺭﺼﺎﻨﻋﻭ ﻉﻭﻗﻭﻟﺍ ﺔﺒﺴﻨ ﻡﻴﻴﻘﺘ لﺠﺃ ﻥﻤ ﺀﺍﺩﻟﺍ ﺍﺫﻬﻟ ﺎﻴﺌﺎﺒﻭ ﻼﻴﻠﺤﺘ ،ﺔﺴﺍﺭﺩﻟﺍ ﻩﺫﻫ ﻥﻤﻀﺘﺘ
ﺤﻤﻟﺍ ﺕﺎﻴﺭﻴﺘﻜﺒﻟﺍ ﺔﻴﻋﻭﻨ ﺩﻴﺩﺤﺘﻭ
ﻡﺘ ﻥﻤﻭ ،ﺽﺭﻤﻟﺍ ﺭﻴﺼﻤﻭ ﺔﻴﺠﻼﻌﻟﺍ ﺔﻴﺠﻴﺘﺍﺭﺘﺴﻹﺍ ﺍﺫﻜﻭ ﺎﻬﺘﻤﻭﺎﻘﻤ ﻁﻤﻨﻭ ﺔﻴﻠ
لﺌﺎﺴﻭﻟﺍ ﺝﺎﺘﻨﺘﺴﺍ
ﺔﻴﺌﺎﻗﻭﻟﺍ
.
ﻥﻤ ﺔﻨﻭﻜﻤ ﺔﻋﻭﻤﺠﻤ ﻥﻤ ﺔﻴﺩﺎﻌﻴﺘﺴﻹﺍ ﺔﺴﺍﺭﺩﻟﺍ ﻩﺫﻫ ﻥﻭﻜﺘﺘ
109
ﺔﻴﺎﻨﻌﻟﺍ ﺡﺎﻨﺠﺒ ﻡﻫﺅﺎﻔﺸﺘﺴﺍ ﻡﺘ ﺽﻴﺭﻤ
ﻥﻴﺒ ﺎﻤ ﺵﻜﺍﺭﻤﺒ ﺱﺩﺎﺴﻟﺍ ﺩﻤﺤﻤ ﻲﻌﻤﺎﺠﻟﺍ ﻰﻔﺸﺘﺴﻤﻟﺎﺒ ﺓﺯﻜﺭﻤﻟﺍ
2003
ﻭ
2007
ﺍﻭﻨﺎﻋ ﻥﻴﺫﻟﺍﻭ
ﻱﻭﺌﺭ ﺏﺎﻬﺘﻟﺍ ﻥﻤ
ﺔﺒﺴﻨﺒ ﺔﻴﻋﺎﻨﻁﺼﻹﺍ ﺔﻴﻭﻬﺘﻟﺍ ﻥﻋ ﺞﺘﺎﻨ
4.24
%
.
ﺯﻴﻜﺭﺘﻟﺍ ﻊﻤ ﺔﻴﺠﻭﻟﻭﻴﺭﻴﺘﻜﺒﻭ ﺔﻴﻋﺎﻌﺸ ،ﺔﻴﺠﻭﻟﻭﻴﺒ ،ﺔﻴﺭﻴﺭﺴ ﺭﻴﻴﺎﻌﻤ ﻰﻠﻋ ﺽﺭﻤﻟﺍ ﺍﺫﻫ ﺹﻴﺨﺸﺘ ﺩﻤﺘﻌﻴ
،ﺔﻴﺌﺍﻭﻬﻟﺍ ﺏﻌﺸﻟﺍ ﻥﻤ ﺓﺩﻴﻌﺒ ﺔﻴﻤﺤﻤ ﺕﺎﻨﻴﻋ ﺫﺨﺃ ﻰﻠﻋ ﺱﺎﺴﻷﺎﺒ ﺎﻨﺘﺴﺍﺭﺩ ﻲﻓ
ﻤﺒ ﻲﺴﻴﺌﺭﻟﺍ ﺭﻁﺨﻟﺍ لﻤﺎﻋ ﺔﻴﻋﺎﻨﻁﺼﻻﺍ ﺔﻴﻭﻬﺘﻟﺍ ﺓﺩﻤ ﺩﻌﺘ
ﻁﺴﻭﺘ
15
ﺎﻤﻭﻴ
)
10،09
(
ﻡﺍﺭﻐﻟﺍ ﺔﻴﺒﻠﺴﻟﺍ ﺕﺎﻴﺼﻌﻟﺍ لﺜﻤﺘ
61,4%
ﺔﻟﻭﺯﻌﻤﻟﺍ ﻡﻴﺜﺍﺭﺠﻟﺍ ﻉﻭﻤﺠﻤ ﻥﻤ
)
ﺔﺒﺴﻨﺒ ﺱﺎﻨﻭﻤﻭ ﺩﻭﺴﺒﻟﺍ
38,5%
ﺔﺒﺴﻨﺒ ﻲﻨﺎﻤﻭﺒﺭﻴﺘﻜﺎﺒﻭﺘﻴﻨﻴﺴﻷﺍ ،
%
22،7
ﺔـﺒﺴﻨﺒ ﻲﻜﺍﻭﻠﻜ ﺭﻴﺘﻜﺎﺒﻭﺭﻴﺘﻨﻭﻷﺍ
%
11،3
(
لﺜﻤﺘ ،
ﻡﺍﺭﻐﻟﺍ ﺔﻴﺒﺎﺠﻴﻹﺍ ﺕﺍﺭﻭﻜﻤﻟﺍ
30,5%
ﻌﻟﺍ ﺎﻬﺴﺃﺭ ﻰﻠﻋﻭ ﻡﻴﺜﺍﺭﺠﻟﺍ ﻉﻭﻤﺠﻤ ﻥﻤ
ﺔﻴﺴﺎﺴﺤ ﺕﺍﺫ ﺔﻴﻨﻬﻟﺍ ﺔﻴﺩﻭﻘﻨ
ﻥﻴﻠﺴﺘﻤﻠﻟ
)
ﺱﻤﺎﺴ
(
لﻜﺸﺘ ﻲﺘﻟﺍﻭ
24,7%
ﺱﻤﺎﺴ ﺙﻴﺤﺒ
/
ﻡﻏﺎﺴ
=
0،33
)
ﺔﻤﻭﺎﻘﻤ ﺔﻴﺒﻫﺫﻟﺍ ﺔﻴﺩﻭﻘﻨﻌﻟﺍ ﻡﻏﺎﺴ
ﻥﻴﻠﺴﺘﻤﻠﻟ
(
،
ﺔﺒﺴﻨﺒ ﺝﻭﺩﺯﻤﻟﺍ ﺝﻼﻌﻟﺍ لﺎﻤﻌﺘﺴﺍ ﻰﻠﻋ ﺱﺎﺴﻷﺎﺒ ﺔﻴﻭﻴﺤﻟﺍ ﺕﺍﺩﺎﻀﻤﻟﺎﺒ ﺝﻼﻌﻟﺍ ﺩﻤﺘﻌﻴ
%
57،8
لﺒﺎﻘﻤ
%
38،5
ﻴﻜﺭﺘﻟﺍ ﻊﻤ ﻲﺜﻼﺜﻟﺍ ﺝﻼﻌﻟﺍ لﺎﻤﻌﺘﺴﺍ ﺕﻨﻤﻀﺘ ﺔﻟﺎﺤ
ﻡﻴﻨﻴﺒﻤﻹﺍ ﻰﻠﻋ ﺎﻨﺘﻋﻭﻤﺠﻤ ﻲﻓ ﺱﺎﺴﻷﺎﺒ ﺯ
ﺔﺒﺴﻨﺒ ﺔﻴﻭﻴﺤﻟﺍ ﺕﺍﺩﺎﻀﻤﻟﺎﺒ ﺞﻬﻨﻤﻤ ﺝﻼﻋ ﺭﺎﻁﺇ ﻲﻓ ﻥﻴﺴﺎﻜﻴﻤﻷﺍﻭ
%
49
ﺔﺒﺴﻨﺒ ﻲﻟﺎﻤﺘﺤﺍ ﺝﻼﻋ لﺒﺎﻘﻤ
%
51
،
ﺏ ﺕﺎﻴﻓﻭﻟﺍ ﺔﺒﺴﻨ ﺭﺩﻘﺘ
%
51،4
لﺒﺎﻘﻤ ﺎﻨﺘﻋﻭﻤﺠﻤ ﻲﻓ
%
48،6
،ﺔﻴﺤﺼﻟﺍ ﺎﻬﺘﻴﻌﻀﻭ ﺕﻨﺴﺤﺘ ﺔﻟﺎﺤ
ﺔﻤﺩﻘﻤﻟﺍ ﺔﻴﺎﻨﻌﻟﺎﺒ ،ﺽﻴﺭﻤﻟﺍ ﺹﺌﺎﺼﺨﺒ ﺽﺭﻤﻟﺍ ﺍﺫﻫ ﺭﻴﺼﻤ ﻕﻠﻌﺘﻴ
ﺔﻴﻭﻴﺤﻟﺍ ﺕﺍﺩﺎﻀﻤﻟﺍ ﺓﺩﻤﻭ ﺔﻴﻋﻭﻨﺒﻭ
.
ﻁﻭﺭﺸ ﺓﺎﻋﺍﺭﻤ ﻰﻠﻋ ﺱﺎﺴﻷﺎﺒ ﺓﺯﻜﺘﺭﻤﻟﺍ ﺔﻴﺌﺎﻗﻭﻟﺍ ﺭﻴﺒﺍﺩﺘﻟﺍ ﻥﻤ ﺔﻋﻭﻤﺠﻤ ﺽﺭﻌﻨ ﺔﺴﺍﺭﺩﻟﺍ ﻩﺫﻫ ﺔﻴﺎﻬﻨ ﻲﻓ
ﺏﻴﻟﺎﺴﻷﺍ ﻩﺫﻬﻟ ﺔﺒﺴﻨﻟﺎﺒ ﺞﻟﺎﻌﻤﻟﺍ ﻡﻗﺎﻁﻠﻟ ﺭﻤﺘﺴﻤﻟﺍ ﻥﻴﻭﻜﺘﻟﺍﻭ ﺭﻴﻬﻁﺘﻟﺍ
.
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